Palliative gastrectomy for advanced gastric cancer.

BACKGROUND/AIMS: Although palliative gastrectomy for advanced gastric cancer may be favorable in selected patients presenting with bleeding and obstruction, little has been reported about the clinical significance of palliative gastrectomy, including prognosis. METHODOLOGY: A retrospective comparison between 84 patients with palliative gastrectomy (PG group) and 100 patients with unresectable operation (UO group) for advanced gastric cancer was carried out. RESULTS: The incidence of serosal invasion, peritoneal dissemination, hepatic and lymph node metastases, and undifferentiated tissue type in the UO group were significantly higher than in the PG group. Median survival after operation in the PG group (20.6 months) was significantly longer than in the UO group (5.7 months). Also, in stage IVb patients, median survival time in the PG group (10.2 months) was significantly longer than in the UO group (5.0 months). However, median survival in the patients with synchronous liver metastasis between PG (8.4 months) and UO (4.6 months) groups was not significantly different. Survival rates after operation of 6 months, 1 year and 2 years in all patients between the palliative gastrectomy group versus UO group were 83.6% versus 38.3% (P < 0.01), 63.0% versus 9.3% (P < 0.01) and 35.2% versus 0% (P < 0.01), respectively. CONCLUSIONS: Palliative gastrectomy compared to unresectable operation may be effective for improvement of prognosis even if stage IVb patients with peritoneal dissemination and/or distant lymph node metastasis. However, it may be unfavorable on survival of patients with synchronous liver metastasis.

Familial gastrointestinal stromal tumor with hyperpigmentation: association with a germline mutation of the c-kit gene.

We describe 2 siblings with multiple gastrointestinal stromal tumors (GISTs) and cutaneous hyperpigmentation. Both had a point mutation of the c-kit gene. The patients were sisters who had exhibited cutaneous hyperpigmentation since their late teens, but the diagnosis of multiple gastrointestinal submucosal tumors was not made until they were 41 and 45 years old. Histologic examination showed that these tumors were GISTs expressing CD34 and Kit protein. Both patients died of GISTs. Single-strand conformation polymorphism analysis showed a mutation of c-kit in tumor DNA extracted from paraffin-embedded specimens. Direct sequencing analysis showed that the point mutation occurred at codon 559 of exon 11 (Val-->Ala). The same single-point mutation was detected in DNA extracted from peripheral leukocytes obtained from the younger sister and her 2 children (who had similar general hyperpigmentation) as well as in DNA from a skin biopsy specimen taken from the older sister. The germline mutation at codon 559 of the c-kit gene found in the present familial GISTs differed from that in a previously reported case of familial GISTs. We propose that GISTs caused by a germline mutation of the c-kit gene should be referred to as GIST-cutaneous hyperpigmentation disease.

Surgical outcome in cirrhotic patients with hepatitis C-related hepatocellular carcinoma.

BACKGROUND/AIMS: The aim of this study was to clarify the surgical outcome in cirrhotic patients with hepatitis C-related hepatocellular carcinoma (HCC). METHODOLOGY: The surgical outcome of 26 HCVAb-positive cirrhotic patients with hepatitis C antibody (the C-related HCC group) and 18 HCVAb-negative cirrhotic patients with (the non-C-related HCC group) undergoing hepatectomy for HCC were compared. The C-related HCC group was HCVAb[+], HBsAg[-] for hepatitis B surface antigen in 25 patients and HCVAb[+], HBsAg[+] in 1, and the non C-related HCC group was HCVAb[-], HBsAg[+] in 15 and HCVAb[-], HBsAg[-] in 3. RESULTS: Preoperative aspartate and alanine aminotransferase in the C-related HCC group were significantly (P < 0.01) higher than in the non-C-related HCC group. There were no significant differences in the operative method, intraoperative blood loss and weight of resected liver or pathological data between the 2 groups. In the recurrence pattern, the incidence of multicentric occurrence in the C-related HCC group (53.3%) was significantly (P < 0.05) higher than in the non-C-related HCC group (7.7%). The mortality rate in both groups was 0% and no operative death was encountered. The crude survival and disease-free survival rates at 3 years were similar: 80.8% and 57.7% in the C-related HCC group and 77.8% and 55.6% in the non-C-related HCC group, respectively. CONCLUSIONS: Although surgically treated cirrhotic patients with C-related HCC showed worse preoperative hepatitis status and a higher incidence of recurrence due to multicentricity compared with non-C-related HCC, the mortality and prognosis of patients with C-related HCC did not differ from that of non-C-related HCC. The indication of hepatic resection and consideration for the high incidence of postoperative multicentric occurrence in the patients with C-related HCC should therefore be more careful than in patients with non-C-related HCC.

Hepatectomy of cavernous hemangioma with constitutional indocyanine green excretory defect.

The constitutional ICG excretory defect with marked ICG retention in spite of other normal hepatic functions has not been so rare in Japan. However, there is no previous report of hepatectomy in a patient with this disease. We describe a successful case of hepatectomy for cavernous hemangioma with this disease and use of technetium-99m diethylenetriaminepentaacetic acidgalactosyl-human serum albumin (99mTC-GSA) liver scintigraphy as the preoperative assessment of the liver functional reserve. In our case, ICGR15 was more than 55%, however, a modified receptor index obtained from 99mTC-GSA liver scintigraphy was normal. Left lateral segmentectomy of the liver was performed without any perioperative complications. Hepatectomy of patients with the constitutional ICG excretory defect is possible if modified receptor index value obtained from 99mTC-GSA scintigraphy is within the normal range.

Postoperative chemotherapy in elderly patients with advanced gastric cancer.

BACKGROUND/AIMS: The definitive efficacy of postoperative chemotherapy in elderly patients with advanced gastric cancer has not been established. The aim of this study is to evaluate prognosis in elderly patients with advanced gastric cancer and the effect of postoperative chemotherapy on prognosis. METHODOLOGY: Fifty-three patients, 75 years of age or older who underwent curative surgery for advanced gastric cancer were divided into 14 patients with postoperative chemotherapy (chemotherapy group) and 39 patients without postoperative chemotherapy (control group). Chemotherapy regimens were as follows: oral 5-FU alone (n = 11), intravenous mitomycin plus 5-FU: MF (n = 2), and MF plus oral 5-FU (n = 1). No prior chemotherapy or radiation was given. RESULTS: There were no significant differences of clinical and pathological backgrounds between the two groups. The rate of death due to recurrent carcinoma was 50.0% in the chemotherapy group and 43.6% in the control group, the difference being insignificant. Although the median survival time of the chemotherapy group (40.4 months) was longer than in the control group (31.7 months), a significant difference did not exist between the groups. The 1-, 3-, and 5-year survival rates did not significantly differ between the chemotherapy group versus the control group, 85.7% versus 82.1%, 42.9% versus 51.3%, and 35.7% versus 46.2%, respectively. CONCLUSIONS: Postoperative chemotherapy did not contribute to prolong survival in elderly patients with advanced gastric cancer mainly because the incidence of recurrent carcinoma was not reduced.

Efficacy of extended lymphadenectomy in the noncurative gastrectomy for advanced gastric cancer.

BACKGROUND/AIMS: We retrospectively analyzed clinicopathologic data on 83 patients with advanced gastric cancer who underwent noncurative gastrectomy, with respect to the relation between the extent of lymphadenectomy and survival benefit. METHODOLOGY: These 83 patients were divided into 44 patients with limited or simple lymph node dissection (D0 in 14 and D1 in 30: Group A) and 39 patients with extended lymph node dissection (D2: Group B). RESULTS: The 1-year survival rate in Group B (82.1%) was significantly higher than in Group A (49.0%). However, the 3-year and 5-year survival rates did not significantly differ between Group A versus Group B, 39.7% versus 25.7% and 39.7% versus 20.5%, respectively. Median survival time after surgery with and without distant metastasis in Group B (21.5 months) was longer than in Group A (16.4 months), although not significant. CONCLUSIONS: While gastrectomy with extended lymphadenectomy did not contribute to improve long-term survival in patients with noncurable advanced gastric cancer, the utility of extended lymph node dissections may be relevant to improved locoregional control, at least in the prognosis within 1 year after surgery. Not only extended lymphadenectomy but also aggressive chemotherapy may be needed to improve the long-term survival for such patients.

Post-operative chemotherapy in non-curative gastrectomy for advanced gastric cancer.

BACKGROUND/AIMS: The definitive effects of post-operative chemotherapy for prolonging survival in patients with non-curative gastrectomy for advanced gastric cancer have not been established. METHODOLOGY: Eighty-three patients with advanced gastric cancer who underwent non-curative gastrectomy were divided into 49 patients with post-operative chemotherapy (chemotherapy group) and 34 patients without post-operative chemotherapy (control group). Chemotherapy regimens were as follows: oral 5-fluorouracil (5-FU) alone (n = 22), intravenous mitomycin (MMC) plus 5-FU (n = 20), intravenous methotrexate (MTX) plus 5-FU (n = 3), intravenous cisplatin plus 5-FU (n = 2), and hepatic arterial infusion of 5-FU plus oral 5-FU (n = 2). No prior chemotherapy or radiation therapy was given. RESULTS: Although the age in the control group (mean: 71.9 years) was significantly older than in the chemotherapy group (mean: 66.1 years), there were no significant differences in the other clinical and pathological background data between the two groups. The 1-year survival rate in the chemotherapy group (71.4%) was significantly higher than in the control group (50.0%). However, the 3-year and 5-year survival rates did not significantly differ in the chemotherapy group versus the control group, 30.6% vs. 32.4% and 24.5% vs. 32.4%, respectively. Although a significant difference did not exist between the two groups, median survival after operation in the chemotherapy group (20.5 months) was longer than that in the control group (16.2 months). Furthermore, median survival of patients with peritoneal dissemination in the chemotherapy group (16.4 months) was significantly longer than that in the control group (7.7 months). CONCLUSIONS: Post-operative chemotherapy may contribute to prolonged survival in patients with non-curable advanced gastric cancer, even when patients had peritoneal dissemination. However, the long-term survival rate was not improved by post-operative chemotherapy. More aggressive chemotherapy may be needed to improve the long-term prognosis for such patients.

Bile leakage resulting from clip displacement of the cystic duct stump: a potential pitfall of laparoscopic cholecystectomy.

We present the case of a patient who underwent successful endoscopic nasobiliary drainage (ENBD) for bile leakage resulting from clip displacement of the cystic duct stump sustained during a laparoscopic cholecystectomy (LC). This 69-year-old man was admitted with symptomatic cholecystolithiasis. After LC was performed, intraoperative cholangiography (IOC) revealed no abnormal findings. However, postoperatively, bilious material began to appear from the intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage from the end of the cystic duct stump. ENBD was performed. Cholangiography using the ENBD tube 14 days later failed to show a bile leak. The ENBD was subsequently removed. The patient improved rapidly with no complaints. Bile leakage due to clip displacement from the cystic duct stump is a potential pitfall of LC, especially if IOC is normal. We recommend careful cystic duct ligation, combined with the use of superior quality ligation clips, to prevent this complication. ENBD is a useful technique to prevent bile leakage after this complication.

Hepatic function immediately after hepatectomy as a significant risk factor for early recurrence in hepatocellular carcinoma.

BACKGROUND/AIMS: The aim of this study was to clarify the significant risk factors as they relate to early recurrence after hepatectomy in cirrhotic patients with hepatocellular carcinoma (HCC). METHODOLOGY: We retrospectively investigated 42 cirrhotic patients undergoing hepatectomy for a single HCC. We compared the clinicopathologic features of 14 patients with early intrahepatic recurrence (recurrence was detected within 1 year after hepatic resection; Group 1) with 28 patients without recurrence or with late intrahepatic recurrence (recurrence was confirmed more than 1 year after hepatic resection; Group 2). RESULTS: There were no significant differences in the pre-operative and intra-operative clinical background data or pathological data between the 2 groups. Regarding recurrence pattern, although not significant, the incidence of intrahepatic metastasis in Group 1 (85.7%) was higher than in Group 2 (50.0%). Maximum values of total bilirubin and albumin within 7 days after hepatectomy for patients in Group 2 were significantly better than those in Group 1. Aspatate aminotransferase (AST) and alanine aminotransferase (ALT) immediately after hepatectomy in Group 1 were also higher than in Group 2, although statistically insignificant. The overall 1-year and 3-year survival rates between Group 1 versus Group 2 were 85.7% versus 100% (p < 0.01) and 57.2% versus 90.0% (p < 0.01), respectively. CONCLUSIONS: Hepatic functional damage immediately after hepatectomy is as significant risk factor for early intrahepatic recurrence in cirrhotic HCC. Careful perioperative management of hepatic function may therefore be important in preventing early recurrence and prolonging survival.

Arterial ketone body ratio and adenosine triphosphate concentration in hepatic ischemia and reperfusion.

BACKGROUND/AIMS: The arterial ketone body ratio (AKBR) and the cellular adenosine triphosphate (ATP) concentration have been proposed as indicators of liver function. However, recent studies of the utility of the AKBR as a biochemical marker have been called into question. Furthermore, there is no practical data defining the relationship between ATP concentration and ischemia-reperfusion (IR) changes during liver surgery. METHODOLOGY: The relationship of the AKBR and arterial ATP concentration to IR during hepatectomy was investigated. In 20 patients who underwent hepatectomy, arterial acetoacetate, beta-hydroxybutyrate, and ATP concentrations were measured. The ratio of acetoacetate to beta-hydroxybutyrate (AKBR) was calculated before and after vascular occlusion. RESULTS: The AKBR 15 minutes after clamping was lower than the preclamping values in all of the patients. It increased after unclamping, returning toward the preclamping levels. An AKBR of less than 0.5 prior to clamping did not correlate with preoperative hepatocellular function. An AKBR of less than 0.7 throughout IR was not a consistent risk factor for postoperative complications and liver dysfunction. The arterial ATP concentration did not correlate with the changes during IR or with preoperative hepatocellular function. CONCLUSIONS: Although the AKBR changed during IR as a general indicator of cellular activity, the absolute value of the AKBR was not an accurate predictor of liver function. The arterial ATP concentration also was not a suitable clinical biochemical marker of hepatic function.

Significant risk factors of recurrence in muscularis proprial carcinoma of the stomach.

BACKGROUND/AIMS: The aim of this study is to elucidate significant risk factors of recurrence in muscularis proprial gastric cancer (MPGC). METHODOLOGY: Seventy-three patients who underwent curative gastrectomy for MPGC were divided into 14 patients with postoperative recurrence (Group 1) and 59 patients without recurrence (Group 2). A retrospective study of Group 1 compared the clinicopathological features with Group 2. RESULTS: There were no significant differences of age, gender and operative method including frequency of lymph node dissection between Group 1 and Group 2. Although tumor size, gastric location and histological type did not significantly differ between the two groups, the rate of Borrman type in Group 1 (71.4%) was significantly higher than in Group 2 (42.4%). Significant risk factors of recurrence in pathological findings were the presence of secondary lymph node metastasis or more, lymphatic and venous involvement. Median survival in Group 1 (28.8 months) was significantly worse than in Group 2 (59.0 months). The 1-year, 3-year, and 5-year survival rates between Group 1 versus Group 2 were 71.4% versus 98.3% (p<0.01), 28.6% versus 96.7% (p<0.01), and 7. 1% versus 95.0 (p<0.01), respectively. CONCLUSIONS: Prognosis of the postoperative recurrence in MPGC was very poor. More careful prophylactic treatment against recurrence of MPGC should therefore, be prescribed in patients with the aforementioned risk factors of recurrence.

Long-term survivor with liver metastases from rectal cancer treated by hepatectomy after hepatic arterial infusion chemotherapy.

A 58-year-old man who had rectal cancer with synchronous hepatic metastases of bilateral lobe is described in this case report. Anterior resection for rectal cancer was performed, and subsequent hepatic arterial infusion (HAI) chemotherapy for liver metastases was continued. Nine months later, although right hepatic metastases showed complete remission after chemotherapy, metastases of the left lateral segment were still remained. Left lateral segmentectomy of the liver was performed. HAI chemotherapy has continued for 17 months after hepatectomy to prevent intrahepatic recurrence of the tumor. The patient has been no evidence of recurrence including hepatic metastasis, and he is still doing well 8 years after initial HAI chemotherapy. A review of the literature reveals that this patient has survived longer than any other patient has with hepatic metastases from colorectal cancer treated by this approach. We suggest that this form of therapy should be considered for future patients.

Postoperative chemotherapy may improve prognosis in unresectable gastric cancer.

We have retrospectively evaluated to prognosis of patients with unresectable gastric cancer (UGC) and the effect of postoperative chemotherapy on that prognosis. One hundred patients who died of UGC included 37 patients who received postoperative chemotherapy (chemotherapy group) and 63 patients who did not receive postoperative chemotherapy (control group). Chemotherapy regimens were as follows: intravenous mitomycin (MMC) plus 5-fluorouracil (5-FU) (n=15), oral 5-FU alone (n=10), intravenous methotrexate (MTX) plus 5-FU (n=8), intravenous cisplatin plus 5-FU (n=2), and hepatic arterial infusion of 5-FU plus oral 5-FU (n=2). No prior chemotherapy or radiation therapy was given. All patients' cancers were stage IV. Median survival of the chemotherapy group (238 days) was significantly longer than the control group (137 days). The 1-year survival rate in the treated group was 19.0% but only 2.4% in the control group (p < 0.01). Patients with palliative gastrojejunostomy did not survive significantly longer than those having laparotomy alone or ileal tube insertion. We conclude that the prognosis for patients with UGC remains very poor, but postoperative chemotherapy may contribute to prolonged survival in patients with UGC.

Carcinoembryonic antigen and intra-arterial chemotherapy response of liver metastases.

BACKGROUND/AIMS: We investigated the relationship between serum carcinoembryonic antigen and response to hepatic artery chemotherapy for unresectable colorectal liver metastases. METHODOLOGY: The study included 14 patients with unresectable colorectal liver metastases receiving hepatic arterial chemotherapy weekly. Patients were evaluated monthly including liver function tests and carcinoembryonic antigen. Ten patients received high dose 5-fluorouracil (1000 mg/m2) and 4 patients received other regimens. One patient underwent hepatectomy for cure after 5-fluorouracil. RESULTS: Thirteen patients (93%) had normal quality of life without toxicity during hepatic artery infusion. Response rate in the high dose 5-fluorouracil group was 50%, while the response rate of other regimens was 25%. Mean survival time differed between responding (n = 6) and non-responding patients (n = 8) (527 vs 289 days), and the high dose 5-fluorouracil (n = 10) and other regimens (n = 4) (462 vs 213 days). In responding patients, peak serum carcinoembryonic antigen levels before hepatic artery infusion decreased within 6 months. In the non-responding patients, serum carcinoembryonic antigen levels increased rapidly despite hepatic artery infusion. CONCLUSIONS: Serum carcinoembryonic antigen levels correlated well with response. Hepatic artery infusional chemotherapy with high dose 5-fluorouracil may be recommended as effective treatment for unresectable liver metastasis from colorectal cancer if serum carcinoembryonic antigen levels decrease within 6 months.

Arterial ketone body ratio does not correlate with ischemic changes during major hepatectomy.

BACKGROUND/AIMS: The arterial ketone body ratio (AKBR) has been proposed as an accurate indicator of hepatic mitochondrial redox potential. However, recent studies of the utility of the AKBR as a biochemical marker have been called into question. It is not clear whether the AKBR is closely related to ischemic changes during major hepatectomy. METHODOLOGY: Arterial acetoacetate and beta-hydroxybutyrate concentrations were measured in eleven patients who underwent major hepatectomy. The ratio between them (AKBR) was calculated before and after vascular occlusion during the hepatectomy procedure. RESULTS: The AKBR increased following normothermic arterial or portal venous ischemia as compared to the levels prior to vascular occlusion in 36.4% of the patients who underwent major hepatectomy. An AKBR of less than 0.5 prior to vascular occlusion did not correlate with preoperative hepatocellular function. An AKBR of less than 0.7 throughout surgery was not a consistent risk factor for postoperative complications or liver dysfunction. CONCLUSIONS: The AKBR does not correlate with ischemic changes or postoperative complications after major hepatectomy.

Hepatic metastasis from esophageal cancer treated by surgical resection and hepatic arterial infusion chemotherapy.

We herein describe a successful surgical resection of esophageal cancer with syncronous liver metastasis and report the first case of a partial response to hepatic arterial infusion chemotherapy for recurrence of esophageal hepatic metastasis after hepatectomy. Hepatectomy and subsequent hepatic arterial infusion chemotherapy with cisplatin and 5-fluorouracil is thus recommended as an effective treatment for liver metastasis from esophageal cancer.

Surgery for gastric cancer in patients older than 80 years of age.

BACKGROUND/AIMS: Although the number of elderly patients who undergo surgery for gastric cancer has increased in recent years, the clinical features associated with this group of patients, including their postoperative survival rate, remain unclear. METHODOLOGY: The cases of 50 patients > or = 80 years of age (the older group) with gastric cancer who underwent surgical treatment in our Department from January 1988 to December 1995 were reviewed and compared to the records of 239 patients < or = 60 years of age (the younger group) who had surgery during the same time period. RESULTS: The incidence of advanced gastric cancer in the older versus younger groups was 59.6% versus 27.9%, respectively (p < 0.01). The tumor size was significantly larger in the older group. The tumor location in the older group predominantly involved the upper third of the stomach, while in the younger group, the middle third of the stomach was primarily involved. Histologically, the incidence of differentiated tumor types was 65.1% versus 50.5% (p < 0.05), and undifferentiated types, 34.9% versus 49.5% (p < 0.05), in the older and younger groups, respectively. Retrospective comparisons conducted between the older and younger groups revealed the following: curative resectability rate: 52.0% versus 74.5% (p < 0.01); hospital mortality rate: 2% versus 0%; overall 5-year survival rate: 46.1% versus 71.1% (p < 0.01); and a 5-year survival rate in patients who underwent curative resection of 65.0% versus 88.8% in the older versus younger age groups, respectively. CONCLUSIONS: These results suggest that the survival of elderly patients with gastric cancer is worse than that of younger patients because of a lower curative resection rate of the advanced cancer. However, the survival rate in elderly patients is identical to that in younger patients if a curative resection is performed.

[Anesthesia for a patient with macrothrombocytopenia].

A 56-year-old female with macrothrombocytopenia was scheduled for colectomy and hepatectomy. She had not shown significant bleeding tendency. Her preoperative platelet counts were 0.5-1.6 x 10(4) microliters-1 with the use of an automated cell counter. However, microscopic examination showed platelet number ranging 0.9-3.4 x 10(4) microliters-1 and many macrothrombocytes. Therefore, platelet biomass (platelet number x platelet volume) seemed almost normal. Bleeding time was 3 minutes and platelet function was normal. She received preoperatively high dose gamma-globulin administration and intraoperatively platelet transfusion. The operation was performed under combined epidural and general anesthesia. Intra- and post-operative course was uneventful.

Arterial ketone body ratio during hepatectomy.

The arterial ketone body ratio (AKBR) has been proposed as an accurate indicator of liver mitochondrial redox potential. However, the efficacy of the AKBR as a biochemical marker has been recently called into question. To resolve this issue, we studied the effect of temporary vascular occlusion on the AKBR during hepatectomy. Twenty patients undergoing hepatectomy were divided into two groups: those with hepatocellular carcinoma with a history of hepatic cirrhosis (n = 10; cirrhotic group) and those with liver disease without cirrhosis (n = 10; non-cirrhotic group). To minimize blood loss during hepatectomy, temporary vascular occlusion was applied using the Pringle maneuver. Acetoacetate and beta-hydroxybutyrate concentrations in the arterial blood and the AKBR were determined before and after vascular occlusion. In 25% of the two groups combined, the AKBR increased following normothermic ischemia, as compared with the levels prior to clamping; in 20% of cases in the cirrhotic group, it increased immediately following reperfusion, as compared with the levels prior to clamping. Changes in the AKBR during hepatectomy did not correlate with preoperative hepatocellular function. An AKBR of less than 0.7 prior to clamping which persisted during surgery was not a consistent risk factor for postoperative complications. The AKBR was not a useful predictor of liver viability in partial liver resection with temporary vascular occlusion.